Provider Demographics
NPI:1184600884
Name:NORTH VALLEY DERMATOLOGY LLC
Entity type:Organization
Organization Name:NORTH VALLEY DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:F
Authorized Official - Last Name:FREDENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:623-215-0911
Mailing Address - Street 1:14155 N 83RD AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-5639
Mailing Address - Country:US
Mailing Address - Phone:623-215-0911
Mailing Address - Fax:623-215-0912
Practice Address - Street 1:14155 N 83RD AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-5639
Practice Address - Country:US
Practice Address - Phone:623-215-0911
Practice Address - Fax:623-215-0912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-15
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ16095207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ66036Medicare UPIN